My thanks to all of you who have taken interest in the latest developments in the University of Pittsburgh/UPMC Department of Anesthesiology. Since the department's last newsletter in the fall, there have been many changes, especially as a number of faculty members have transitioned into new roles both within and outside the department.

As was previously announced, John P. Williams, MD, who had chaired the department since 2002, stepped down from that role in November and began a six-month sabbatical. Dr. Williams guided the department through an era of tremendous expansion, both clinically and academically. Under his leadership, the department is now widely considered the largest academic program in the country, with more than 185 faculty and 370 CRNA full-time equivalents who support more than 210,000 procedures at 262 anesthetizing locations, with more than 35,000 chronic pain visits and more than 12,000 obstetrical deliveries annually. We now rank in the top ten anesthesiology departments nationally in federally funded grants, with total research awards exceeding $6.2 million. Our residency program is also widely considered one of the top five in the country, and we have ten active fellowship programs. The department held a reception in honor and appreciation of Dr. Williams' career at the end of January, which was very well attended by his many colleagues and friends.

Since Dr. Williams stepped down, it has been my privilege and pleasure to serve as Interim Chair. The Chair Search Committee, appointed by Dr. Arthur S. Levine (University of Pittsburgh Senior Vice Chancellor for the Health Sciences and Dean of the School of Medicine), has identified a number of highly qualified candidates, and hopefully a new chair will be in place within a few months. I want to thank the department faculty and staff for their remarkable efforts to continue, without fail, the exceptional service they have always provided to UPMC and the University throughout this transitional period. You have my deepest thanks and gratitude.

Sadly, the department lost a prominent faculty member and an esteemed alumnus in recent months. We were shocked to learn of the unexpected and untimely passing of Dr. Dawn Marcus, a chronic pain physician who worked in the department for over 20 years. Dr. Marcus was a highly-regarded expert in the treatment of migraine and fibromyalgia pain. Also, Dr. Ezzat Abouleish, former Chief of Obstetric Anesthesiology at Magee-Womens Hospital of UPMC, passed away in February. Dr. Abouleish had remained in contact with the department and was the focus of an "Alumnus Profile" in a previous issue of this newsletter (Volume 1, No. 2 Winter 2011, page 8). Both Dr. Marcus and Dr. Abouleish will be greatly missed and fondly remembered by many in the department who knew them. Please see the articles about the lives and careers of Dr. Marcus and Dr. Abouleish in this issue.

In the fall we welcomed Ajay D. Wasan, MD, MSc as our new Vice Chair for Pain Medicine and a Visiting Professor of Anesthesiology and Psychiatry in the University of Pittsburgh School of Medicine. Dr. Wasan has particular expertise in interventional procedures, neuropathic pain medications, opioids, psychotropic medication, and the psychiatric co-morbidities of chronic pain. In his new role as Vice Chair for Pain Medicine, he will supervise clinical care across seven hospital pain clinics in the UPMC system, the department's Pain Medicine Fellowship Program, and pain medicine research.

In December, we formally announced the appointment of Jerry R. Clark, MD, FASE to the role of Chief of Anesthesiology at UPMC Mercy Hospital. Dr. Clark had served as the Interim Chief of UPMC Mercy since January of 2013. In addition to his role as Chief, Dr. Clark continues to function in multiple roles facilitating the education of medical students, residents, and fellows and serve as the Adult Cardiothoracic Anesthesiology Fellowship Associate Program Director for the University of Pittsburgh School of Medicine.

Finally, this February Mark E. Hudson, MD, MBA (formerly Vice Chair of Clinical Operations) was appointed as Executive Vice Chair of the Department of Anesthesiology. In his new, expanded role, Dr. Hudson will coordinate and manage the delivery of anesthesiology care to patients at all sites, assure department compliance with standards and regulations, and support the department's research and educational missions.

Throughout this time of change, the department continues to generate increasing revenue. Our fiscal year (FY) 2013 annual report showed that our net revenue increased by nearly $4 million between FY 2012 and FY 2013, which was primarily driven by changes in case acuity and billing efficiency. Also, the department netted a 6.92% increase in year-to-date revenue from this time last year. This accomplishment is a testament to the hard work and dedication of our department's excellent physicians, CRNAs, and support staff, who continually strive to improve quality of care while increasing productivity and efficiency.

Thank you to all of our friends and readers who have provided feedback on this newsletter for keeping in touch with us, especially regarding alumni. Please continue telling us what you are up to, what you think of our newsletter, and what kind of articles you would like to see. To submit feedback or suggestions, please contact Christine Heiner here in the department.

Thank you all for your continued support and I wish you all a safe and happy spring!

Alcohol is the most widely used and abused drug in our society. Alcohol use disorders cost the US approximately $235 billion dollars annually and contribute to about 3.5% of deaths [1]. Despite widespread alcohol use, the molecular sites of action of this drug in the nervous system are largely unknown. Much of the research in the Homanics laboratories focuses on uncovering how beverage alcohol (ethanol) exerts its effects on the brain to cause alcohol's many pleasurable effects such as relaxation and anxiety reduction, as well its many problematic effects such as motor incoordination, memory impairment, and of course, addiction. Insight into ethanol's mechanisms of action could ultimately lead to therapeutic interventions to combat alcohol use disorders.

For much of the twentieth century, the prevailing theory on alcohol's action in the brain centered on the idea that alcohol simply dissolved into neuronal membranes and altered brain function nonspecifically. This same lipid-based theory was also the leading candidate to explain inhaled anesthetic action. However, in the past ~25 years, overwhelming evidence has accumulated showing that alcohol (and inhaled anesthetics) are capable of interacting very selectively with numerous protein targets that reside on cell membranes and inside brain cells. Thus, the prevailing theory of alcohol action is currently based on perturbation of brain function by the direct interaction of alcohol and protein targets. Recent atomic level structural studies have even identified putative alcohol binding/interaction sites in water-filled cavities in neuronal proteins [2].

However, a key unresolved issue facing the field is: "Which alcohol - protein interactions mediate the well-known behavioral effects of the drug?" In other words, which targets are biologically relevant? Presently, a seemingly unending list of potential targets could be involved. There are several reasons for this. Alcohol is a very small and simple chemical entity with few structural features. Alcohol is not a very potent drug and because of this, millimolar brain concentrations are required to impact cellular and behavioral responses. At such high concentrations, a chemically nondescript molecule such as alcohol has the potential to interact with thousands of protein targets. The field is currently faced with an overabundance of potential alcohol targets, including immune signaling molecules, calcium channels, potassium channels, protein kinase signaling pathways, the intensely-studied family of pentameric cys-loop ligand-gated ion channels, and many others.

Attempts to dissect the involvement of individual molecules in alcohol's mechanism of action have been frustrated by the lack of potent, specific agonists and antagonists for many putative targets. As an alternative to a classic pharmacologic dissection, the Homanics lab, along with a collection of international collaborators, has utilized a genetic dissection strategy to elucidate the contribution that individual target proteins make to cellular and behavioral responses to alcohol. Animals (mostly mice) are genetically engineered to create lines that differ from controls by a single gene that is potentially involved in alcohol's action on the brain. These designer animals are either gene knockouts in which the gene of interest is nonfunctional, or gene knockins in which the gene has an altered function (e.g., a gene that is normally highly sensitive to alcohol is rendered insensitive). Such animals are then studied for cellular and behavioral responses to alcohol. Differences between mutants and wild type control animals implicate the mutated gene in mediating/modulating that particular response to alcohol.

The Homanics lab has produced numerous lines of genetically engineered rodents that have provided novel insight into the role the targeted gene plays in alcohol action. Considerable effort has been devoted to understanding the contribution of gamma-amminobutyric acid type A receptors. Gene knockout studies of the highly ethanol-sensitive alpha 4 and delta subunits implicate these subunits in ethanol consumption and withdrawal severity [3,4]. Gene knockin studies implicate the alpha 1 subunit in motor impairing and anxiolytic effects, whereas the alpha 2 subunit contributes more to ethanol-conditioned taste aversion and motor stimulation [5].

The traditional approach to creating designer animals is technically demanding, arduous, and very expensive. Creating precise modifications in endogenous genes of interest is a very inefficient process. Because of this, gene targeting must be conducted in cells in culture, where very rare genetic events can be identified and characterized. The key to creating designer mice from gene targeted cells is to use embryonic stem cells for the gene-targeting portion of the experiment. Embryonic stem cells originate from early embryos and retain the ability to differentiate into any cell type of the body. Gene-targeted embryonic stem cells can be microsurgically injected into developing embryos, where they can contribute to the development of the germ cells of the resultant animal. From these animals, true breeding lines of animals can be developed that harbor the mutant gene of interest.

Within the past two years or so, stunning technological advancements have been made that greatly simplify the creation of designer animals. New tools have been developed that allow for genome editing at remarkably high efficiencies. Targeting efficiencies are so high that endogenous genes in early one-cell embryos can be directly modified as desired; embryonic stem cells are not needed. Currently, there are primarily two competing technologies that are being utilized to create designer animals. The first, transcription activator-like effector nuclease (TALEN) technology [6], relies on proteins that bind DNA in a sequence-specific manner to target the gene of interest. TALENs can be created to bind to nearly any DNA sequence of interest. Attached to the TALENs are nucleases that create double stranded breaks in the DNA sequence. Repair of TALEN-induced DNA breaks is a very inaccurate process that typically leads to deletions or insertions in the gene of interest, thereby rendering it nonfunctional (i.e., creating a gene knockout). The second technology, clustered regularly interspaced short palindromic repeats (CRISPR) [7], relies on a short RNA molecule to target the gene of interest. Like TALENs, the CRISPR RNA directs a nonspecific nuclease to disrupt the gene of interest. These techniques are so efficient that multiple genes of interest can even be targeted simultaneously in the same animal [7].

These emerging techniques for creating designer animals appear to be revolutionizing how such animals are made for research. Whereas traditional approaches for creating a single genetically engineered mouse line took about two to five years and cost $50,000-100,000, these new technologies can accomplish the same thing in two to five months with $5,000-10,000. The Homanics lab was one of the first to use TALEN technology to produce a genetically-engineered rat line in which toll-like receptor 4 was inactivated [8].

Designer mice have had a long and fruitful history of advancing our understanding of how alcohol affects the brain and body. Recent technological advances which make the process much faster, easier, and cheaper ensure that designer mice will continue to play a key role in delineating how alcohol action at its molecular targets alters behavior. By understanding these processes, it should be possible to develop desperately needed treatments to combat alcohol use disorders.

Postoperative infections - urinary, pulmonary, surgical site infections (SSIs), sepsis - have serious ramifications for both the patient and hospital, leading to prolonged hospital stays, increased costs, patient dissatisfaction, other short and long term morbidity, and higher mortality rates. The roots of what later manifest as clinical infections are often established during the time a patient is under our care. SSIs, for example, become established in the critical hours after bacterial contamination (i.e. during and immediately following surgery). Therefore, it is important for us to examine those modifiable risk factors under our control.

Preoperative

Certainly comorbid diseases (e.g. diabetes) can contribute to postoperative infectious complications and should be managed in anticipation of surgery, but there are additional interventions that can be of benefit. Surgical trauma causes expression of inflammatory cytokines and PGE2,which in turn decreases macrophage and granulocyte bacterial killing, depresses lymphocyte and natural killer (NK) cell proliferation and function, and stimulates myeloid-derived suppressor cell production of arginase-1. Arginase rapidly depletes arginine stores, which are necessary for proper function of cellular mediated immunity (CMI) [1-3]. Countering this with arginine supplementation preserves postoperative macrophage and lymphocyte function, wound healing, and resistance to infection [4,5]. Omega-3 fatty acids shift eicosanoid synthesis pathways away from PGE2 production, modulating the inflammatory and immunosuppressive response after trauma or surgery [6]. Consumption of ω-3 fatty acids prior to surgery also preserved CMI and reduced postoperative infections and wound complications [7] Clinical trials of an immune-modulating diet (most studies combined arginine and ω-3 fatty acids) in elective surgery found significant reductions in acquired infections, wound complications, and hospital length of stay [8-10]. Immunonutrition was most effective when started before surgery, and supplements should be given for the week prior to surgery [10]. Other preoperative measures for reducing postoperative infections include MRSA screening/decolonization [11] and urging smoking cessation [12].

Intraoperative

We are all familiar with the emphasis on and responsibility for proper choice, dose, timing, and re-dosing of prophylactic antibiotics (the Surgical Care Improvement Project) and the value of these in reducing postoperative infection [13]. Likewise, hospital initiatives limit Foley catheter use and indwelling time. At times, it is we who are the voice of caution in proceeding with implantation of a surgical prosthesis in a patient with an active source of infection (e.g. UTI, dental abscess). We are well aware of the importance and practice of proper hand hygiene [14] and schooled in sterile technique for invasive procedures. It is important that we maintain that awareness when handling drugs, needles, and syringes, and in the routine accessing of lines whether by stopcock or needleless access ports. A recent report showed that even minimal residual propofol in a stopcock presents a significant nidus for bacterial growth and line infection [15]. Syringes should not be re-used and medication syringes should be dated and discarded daily.

The risk of extrinsic contamination, possible with any medication or solution, is especially problematic with propofol. Its lipid carrier readily supports the growth of microorganisms and it has been uniquely associated with outbreaks of extrinsic contamination. The magnitude of the problem may well be underestimated, as this source may go unrecognized. Aseptic handling, including disinfection of the neck of an ampule or the rubber stopper of a vial before use and preparation of propofol immediately before use, is recommended. Filled syringes allowed to stand more than eight hours should be discarded.

Operating room ventilation is highly filtered and its flow designed to minimize airborne wound and sterile field contamination. Unnecessary traffic during the procedure and repeated opening of the OR doors is discouraged as it disrupts that airflow, increases particle and bacterial contamination of the surgical field, and increases risk of an SSI [16-18].

Management of patient ventilation can also impact infectious outcomes. Atelectasis develops soon after induction, is present in most patients, can persist for days after surgery, and is an important risk factor in the pathogenesis of postoperative respiratory failure and pneumonia. The ensuing hypoxemia will adversely affect tissue healing and bactericidal immune function. A strategy of protective lung ventilation aims to avoid, on one end, alveolar overdistention and barotrauma caused by use of high tidal volumes and inspiratory pressures and, on the other end, derecruitment of alveoli. Recommendations include use of CPAP during induction, tidal volumes 6-8 ml/kg (<10ml/kg), sufficient levels of PEEP, recruitment maneuvers after intubation and periodically thereafter, and avoidance of 100% FiO2, particularly at extubation [19-23].

Neutrophil oxidative killing represents a critical line of our immune defense against infection [24]. Oxidative bactericidal activity requires production of superoxide radicals, a chemical reaction catalyzed by NADPH-linked oxygenase and dependent on the partial pressure of oxygen, wherein production falls off sharply below a pO2 of 90 mm Hg. Surgery disrupts the blood supply in the wound, causing localized tissue hypoxemia (often <30 mm Hg) with local impairment of oxidative bactericidal function. Indeed, Hopf et al. [25] showed that wound tissue oxygen tension predicted the risk of wound infection. To counter that local hypoxemia, Grief et al. [26] used high inspired oxygen concentrations intraoperatively (FiO2 80% vs. 30%) and for the first two hours postoperatively, halving the incidence of SSIs. Several meta-analyses support the conclusions of that original report and lend strong support to this practice [27-30].

Perioperative hyperglycemia is well-recognized as an important risk factor for postoperative infection. In a large scale retrospective analysis, 29.1% of patients had perioperative hyperglycemia (defined in the study as >180 mg/dL) with an increased risk of infection (OR 2.0), reoperation (OR 1.29), and death (OR 1.21), where the degree of effectiveness of glucose control correlated with improved outcomes [31] The increased infection risk due to hyperglycemia has been attributed to multiple aberrations of immune cell function, including defects of chemotaxis, phagocytosis, production of reactive oxygen species, and oxidative killing [32,33]. The impaired production of superoxide appears to stem from inhibition of glucose-6-phosphate dehydrogenase [34], an enzyme that catalyzes production of NADPH, a critical electron donor in many intracellular processes [35]. Intraoperative glucose control with insulin preserves neutrophil function although, surprisingly, part of the benefit appears to be due to something other than insulin's effect on glycemic control [36]. In a study of SSIs and neutrophil function in diabetic mice, insulin had a dual benefit on neutrophil function - euglycemia not only restored superoxide production, but also directly enhanced phagocytic and bactericidal activity independent of its euglycemic effect [37].

Hypothermia, even when mild, is associated with an increased rate of postoperative infection [38,39]. Hypothermia impairs the function of both monocytes [40] and neutrophils [41] (both oxidative and phagocytic capacity) and may, because of vasonconstriction and decreased wound tissue pO2, further diminish bactericidal capacity. In one study, even a single intraoperative temperature of less than 35�C doubled the risk of postoperative SSI [42]. Maintaining normothermia with use of a forced air warming device, an intraoperative standard of care for some two decades, has recently been challenged by reports that the devices may both emit airborne contaminants [43] and simultaneously disrupt laminar airflow at the surgical site [44], resulting in increased surgical site and prosthetic joint infections when compared to a conductive fabric warming device [45]. Other researchers have not supported these conclusions and maintain the position that forced air warming does not pose a risk of increased nosocomial infection [46,47]. Current consensus opinion is that (1) intraoperative hypothermia remains a substantial risk for postoperative infection and (2) that although this is an area of concern warranting further study there is, for now, insufficient evidence to justify a change in practice or abandonment of forced air warming [48,49].

Intraoperative fluid administration can also affect postoperative infectious complications. The use of "normal saline" causes hyperchloremic acidosis, a decreased strong ion difference, and apparent metabolic derangement [50,51].A large retrospective observational study compared patients undergoing major open abdominal surgery who received either 0.9% saline or a balanced crystalloid solution and found an in-hospital mortality of 5.6% vs. 2.9%, complication rates of 33.7% vs. 23%, and a significantly higher postoperative infection rate in the 0.9% saline group [52]. Excessive fluid administration is also deleterious. "Restrictive" or "goal-directed" fluid regimens have been shown to reduce the incidence of perioperative complications, including pneumonia and wound infection, decrease duration of ileus, improve wound and anastomotic healing, and decrease hospital length of stay [53-55].

During surgery under general anesthesia, the central nervous system is bombarded with nociceptive input and it responds with a neurohumoral stress response, activating the sympathetic nervous system and hypothalamic-pituitary axis. Catecholamines and cortisol both elicit a cytokine-driven shift of the immune system away from a cell-mediated response [56-60], while catechols directly suppress cytotoxic lymphocytes and NK cells [56,57,61]. Regional anesthesia, by blocking nociceptive afferents, attenuates the stress response with a sparing effect on cytokine balance and immune cell function [62-64]. Consistent with this, patients undergoing hip and knee replacements under neuraxial anesthesia have significantly fewer infections than those having general anesthesia [65,66]. An alternative or supplemental mechanism may be that neuraxial block increases local tissue perfusion (and thus tissue pO2) by both direct vasodilation and indirectly due to less catecholamine-induced vasoconstriction [67]. It remains unknown whether truncal blockade or incomplete blockade intended for postoperative analgesia (e.g. paravertebral or TAP blocks) would provide similar benefit.

Blood transfusion is associated with a dose-related and significantly increased risk of postoperative infection [68-71]. This is typically attributed to transfusion-related immunomodulation (TRIM) [72,73], an immunity suppression associated with transfusion that includes the depressed proliferation and function of monocytes, macrophages, T-cells, and NK cells. Blood storage defects may also contribute to this increased risk of infection. Stiff, poorly deformable red blood cells that do not readily traverse the capillaries and nitric oxide depletion may impair tissue perfusion while depletion of 2,3-DPG shifts the oxyhemoglobin curve leftward, restricting tissue oxygen delivery. These combined effects will decrease oxidative bactericidal immune function, particularly at the surgical site where tissue perfusion may already be impaired. Use of intraoperative cell salvage, conservative blood administration policies, and preoperative vitamin and iron supplements will all contribute to minimizing the need for transfusion.

Speculative

Further unexplored areas of anesthesia care and its relationship to postoperative infection warrant study. Opioids have well-established inhibitory effects on both cellular and humoral immunity [74-76], increasing the susceptibility to and lethality of infections [77]. Are they a risk factor for infection after surgery? Volatile anesthetics have multiple deleterious effects on a broad range of immune cells, including lymphocytes, NK cells, neutrophils, and macrophages, whereas propofol appears to maintain celllular immune function [78]. Microbicidal alveolar macrophage function decreased nearly twice as much in patients receiving isoflurane versus propofol anesthesia [79]. So will total intravenous anesthesia be less of an infectious risk than inhalational anesthesia? Ketamine in low doses blunted the inflammatory response to surgery and preserved the lymphocyte proliferative response to phytohemagglutinin [80,81]. Ketamine also improved survival in experimental sepsis models [82,83]. Neither clonidine nor dexmedetomidine, both alpha-2 agonists, affected chemotaxis, phagocytosis, or superoxide production by human neutrophils [84]. They suppress release of inflammatory cytokines in surgical patients [85], improve survival in experimental sepsis [86], and improve survival in septic ICU patients [87]. Will then the use of low dose ketamine and an alpha-2 agonist, often used in opioid-sparing multimodal analgesia, reduce the infectious complications of surgery? These are suggestive preclinical data - fascinating and a fertile ground for study, but there are presently no clinical data to support the use or avoidance of the above drugs with regard to infectious outcomes in surgical patients.

Conclusion

There are surely many who read the title of this article and thought to themselves, "Nah," or maybe "Not so much," or perhaps "OK, but how'd the Penguins do last night?" But clearly the answer is a resounding "Yes". We in anesthesiology should not consider ourselves passive bystanders to the considerable problem of postoperative infections. In fact, many of the practices and concerns raised here are, or should be, routine for us. Nevertheless, the terrible toll of postoperative infections, the relative ease of implementation of these practices, and their documented benefits compels that we consider them, understand them, and incorporate them into our daily routines.

Figure 1: Anesthesia Care and Postoperative Infections: The Known and the Speculative (click to enlarge)

The Department of Anesthesiology excels in the education of medical students, residents, fellows, and faculty. In addition to teaching in the traditional OR and clinical clerkships, anesthesiology faculty serve on important committees, such as admissions, curriculum, and the medical school executive committee, and serve as research mentors for medical student scholarly projects. Our medical student program is recognized nationally as among the best in the nation and is unique among departments of anesthesiology because of our involvement in the preclinical medical student curriculum.

There is increasing emphasis in graduate medical education on integrating residents and fellows into patient safety and quality activities in the clinical learning environment. This emphasis led to increased involvement of residents and faculty in patient safety activities and the development of a residency program patient safety committee. I and our Residency Program Director David G. Metro, MD presented on this approach and other methods of engaging residents and faculty in patient safety in the specialty and at the institutional level at the Accreditation Council for Graduate Medical Education (ACGME) Educational Conference, which was held from February 27-March 2, 2014 in National Harbor, MD.

Residency Program

Due to changes in the accreditation system, the ACGME extended our residency program accreditation to the maximum time available (until the year 2022). Our annual Resident and Fellow Graduation Ceremony was held on June 7, 2013 at the University Club. Twenty residents and 25 fellows graduated. In the fall, we learned that our entire graduating resident class of 2013 passed the American Board of Anesthesiology (ABA) Part 1 Exam on their first attempt. We began academic year 2013-2014 with a total of 71 residents: 12 new post-graduate year (PGY)-1 residents, 20 PGY-2 residents (including seven new PGY-2 residents), 19 PGY-3, and 20 PGY-4. Dr. Wendy Haft was elected Chief Resident and Drs. Phillip Adams and Trent Emerick were chosen to share the Associate Chief role.

Our 2014 residency match recently concluded. Our Resident Recruitment and Selection Committee, chaired by Dr. Patrick Forte, selected 225 medical students to interview from over 1,000 applications for the upcoming academic year. We are pleased to announce that we had a full complement and matching with 11 of our top 14 candidates. Twelve PGY-1 residents and one new PGY-2 resident will start in June 2014; seven PGY-2 residents will start in July 2015.

Our residents lead the nation in scholarly activity. Collectively, this past year, they published 18 peer reviewed papers, over 30 book chapters, and presented at national meetings over 50 times.

Dr. Trent Emerick (PGY-4) presented a workshop at the 2012 Society for Education in Anesthesia annual meeting entitled "How to Improve Resident Scholarly Activity in Your Department." The article "Facilitation of Resident Scholarly Activity: Strategy and Outcome Analyses Using Historical Resident Cohorts and a Rank-to-Match Population" (Tetsuro Sakai, MD, PhD; Trent D. Emerick, MD; David G. Metro, MD; Rita M. Patel, MD; Sandra C. Hirsch, MBA; Daniel G. Winger, MS; Yan Xu, PhD), which was published as the lead article in the January 2014 issue of Anesthesiology, further demonstrated this work showing that our residents outperformed a matched cohort in scholarly activity. The paper was also featured in the editorial "Avoiding Professional Extinction" by Michael M. Todd, MD and Lee A. Fleisher, MD published in the same issue.

We will host the Pennsylvania Anesthesiology Resident Research Conference here in Pittsburgh on May 10, 2014. Residents throughout the state will present their work to residents, faculty, department chairs, and program directors from all anesthesiology programs in Pennsylvania. Please visit our website for more information or to register.

Fellowship Programs

We host ten fellowship training programs. Our ACGME-accredited fellowships are in the specialties of adult cardiothoracic anesthesiology, anesthesiology critical care medicine, pediatric anesthesiology, and pain medicine, and obstetrical (OB) anesthesiology, which just received its initial accreditation in 2012. Additional fellowships include those in hepatic transplantation anesthesiology, neuroanesthesiology, research, orthopedic anesthesiology, and acute pain and regional anesthesiology, one of the largest US programs in the specialty.

With the departure of our longtime OB anesthesiology fellowship director Dr. Manuel Vallejo in the fallto become Chair of the Department of Anesthesiology at West Virginia University, Patricia Dalby, MD was appointed program director. Ryan C. Romeo, MD subsequently became the Medical Student Coordinator at Magee Womens-Hospital of UPMC.

In great sadness, we regretfully announce that Dr. Dawn A. Marcus passed away on October 19, 2013. Dr. Marcus was a Professor and chronic pain physician at the UPMC Pain Evaluation and Treatment Institute, where she directed the Multidisciplinary Headache Clinic. Dr. Marcus had been a department faculty member since 1990.

Dawn A. Marcus, MD authored over 100 articles and gave numerous training sessions and invited lectures on the topics of chronic pain and headache in the United States and internationally. She was the principal investigator on research projects investigating pain epidemiology, pathology, treatment, and women's issues. Dr. Marcus wrote 17 books on topics such as migraines, chronic pain, fibromyalgia, therapy dogs, and physical fitness. She won the 2007 Excellence in Media Award from the National Headache Foundation for her book Ten Simple Solutions to Migraine.

Dr. Marcus was a well-known and outspoken advocate of dogs' role in psychological wellbeing, fitness, and rehabilitation. She was frequently seen with her Soft-coated Wheaten Terriers Wheatie and Toby. She worked with the Doggie Donation Corps to raise money for the Pawz for Wounded Veterans program through the non-profit service dog organization Canine Support Teams to train and provide service dogs to wounded Veterans at no charge. The Doggie Donation Corps raised over $20,000 for service dogs for wounded Veterans.

Dawn Marcus was very visible in the media, managing numerous websites and blogs. She frequently appeared on radio, on the web, and in magazines to speak about the health topics on which she focused her career. Most recently, she appeared on the cover of the summer 2013 issue of the magazine Fibromyalgia and Chronic Pain Life. In 2013, she was named among the top 10 social healthmakers for "driving the online conversation" on migraine & headaches.

Dr. Marcus will be very sadly missed by all in the department and by the many people she helped throughout her career.

Dr. Ezzat Abouleish

We sadly announce the passing away of Dr. Ezzat Abouleish, former Chief of Obstetric Anesthesiology at Magee-Womens Hospital of UPMC, on February 20, 2014. Dr. Abouleish was a faculty member in our department from 1970-1982.

Below is his son Amr's eulogy:

My father passed away in the early hours of February 20, 2014.

Ezzat Ibrahim Abouleish was a true renaissance man -- artist, writer, philosopher, scientist, physician -- as well as a wonderful husband, father, grandfather -- but more importantly, a great friend to all. Dr. Abouleish was a Professor Emeritus of Anesthesiology and Obstetrics at University of Texas Medical School of Houston and prior to that a Professor of Anesthesiology at University of Pittsburgh. He was a life-long writer and philosopher, but it was after his retirement that Ezzat began his second life -- art and calligraphy.

In all his life, Ezzat's compassion for his fellow man and woman was evident. From being integral in making obstetric anesthesia safe for the laboring woman (every time a woman has a successful epidural analgesia, remember Dr. Abouleish!), to advocating for peace and understanding among all people, to sharing his art and calligraphy with the world, and his love of God, Ezzat touched many lives with love and humor.

Ezzat truly made this world more beautiful, fun, and happy.

He will be missed by his many friends, colleagues, and his wife, Atiya, his children, Hassan, Amr, and Reda, their spouses, and his eight grandchildren.

And take a moment today and smile when you think of Ezzat Abouleish and his beautiful rich life.

Dr. Abouleish remained in contact with the department after his departure and was the focus of an "Alumnus Profile" in our newsletter (Volume 1, No. 2 Winter 2011, page 8). He will be greatly missed and fondly remembered by many in the department who knew him.

Dr. Kathirvel Subramaniam, a Visiting Associate Professor and cardiac anesthesiologist working at UPMC Presbyterian, has been quite busy over the last few years. Since 2011, he has co-edited two textbooks, guest-edited two special journal issues, launched a new journal, and organized and established a new series of annual perioperative & critical care monitoring conferences.

Dr. Subramaniam earned his MBBS and MD in his home country of India from Coimbatore Medical College and All India Institute of Medical Sciences, respectively. He also completed an anesthesiology/critical care medicine residency at All India Institute of Medical Sciences. In 2000, Dr. Subramaniam moved to the United States and completed an Internal Medicine Internship at Long Island College Hospital at State University of Brooklyn in New York. He continued to complete a second anesthesiology/critical care medicine residency at Harvard Medical School in 2004 and a fellowship in cardiothoracic anesthesiology at Cleveland Clinic in 2005.

That year he joined the faculty of the UPMC/University of Pittsburgh Department of Anesthesiology as a Clinical Associate Professor, where he quickly became one of the most popular clinical educators. Dr. Subramaninam won the department's "Clinical Teacher of the Year Award" in 2007, 2008, 2009, 2010, and 2011. He was also chosen by the department's residents to receive the Dr. Leroy Harris Award for Excellence in Teaching for July 2008-June 2009. He currently serves as the director of the Intraoperative Echocardiography Education Rotation for residents and fellows at UPMC Presbyterian.

Dr. Subramaniam transitioned from a primarily clinical role to a primarily academic role in 2013, when he was appointed Visiting Associate Professor. He expects to complete the Multi-disciplinary Master of Public Health (MMPH) program at the University of Pittsburgh, which he has been working on part-time, later this year. Dr. Subramaniam is a member of the Society of Cardiovascular Anesthesiologists (SCA), the International Anesthesia Research Society, and the Society of Transesophageal Echocardiography.

Dr. Subramaniam recently co-organized two important clinical textbooks. In 2011, Anesthesia and Perioperative Care for Aortic Surgery,which he co-authored with Drs. Kyung Park (Ohio State University) and Balachundhar Subramaniam (Harvard Medical School), was published. The book is the first comprehensive reference on anesthesia and perioperative care for aortic surgery, providing detailed descriptions of aortic surgery and anesthesia for specific aortic procedures, including ascending aorta, arch, descending aorta, endovascular surgery, trauma, and surgery for congenital aortic pathologies. The book received excellent reviews from the British Journal of Anaesthesia, Canadian Journal of Anaesthesia, Journal of Neurosurgical Anesthesiology and AORN (Association of Perioperative Registered Nurses) Journal.

In 2014, the first edition of the textbookProblem Based Transesophageal Echocardiography was published. Dr. Subramaniam co-edited the textbook with Drs. Deepak K. Tempe (Maulana Azad Medical College in New Delhi, India), Bala Subramaniam, and Harish Ramakrishna (a UPMC Anesthesiology alumnus, currently at Mayo Clinic). Dr. Subramaniam is working with Dr. Tetsuro Sakai from our department on a new textbook, Anesthesia and Perioperative care for Organ Transplantation, to be published by Springer in the next year.

In 2012, Dr. Subramaniam guest-edited two special journal issues: the June 2012 issue of Best Practice & Research Clinical Anaesthesiology, which focused on the topic of mechanical circulatory support and the summer 2012 issue ofInternational Anesthesiology Clinics, which focused on the role of anesthesiologists in heart failure therapy. TheJournal of Perioperative Echocardiography, which Dr. Subramaniam edits with Bala Subramaniam, was launched with the publication of the first issue in March of 2013. Dr. Subramaniam has also been invited to speak at many national (including the SCA and American Society of Anesthesiologists annual meetings) and international meetings (such as the Asian and Indian Societies of Cardiac Anesthesia).

Drs. Subramaniam and Stephen A. Esper served as the course directors for the First Annual Perioperative & Critical Care Monitoring Conference in Pittsburgh on August 24-25, 2013, where national experts presented current standards and recent advances in the fields of perioperative and critical care monitoring. A hemodynamic, hands-on workshop was the major highlight of the conference (read more about the conference on our website). The second conference is currently scheduled for September 6-7, 2014 (see below under "Upcoming Conferences") with a pre-conference Perioperative Echocardiography Workshop on September 5.

The first SSH Sim Ops Symposium boasted over 280 attendees - the largest gathering of healthcare simulations operations and technical professionals ever! As a professional in the emerging field of simulations operations you cannot afford to miss SSH Sim Ops Pittsburgh 2014.

Dedicate two days to Sim Ops for an educational experience like no other.

Peter M. Winter Institute for Simulation Education and Research (WISER)

May 22, 2014

9:00 am - 12:00 pm

Please visit our website for a preliminary program and call for abstracts.

WISER Maintenance of Certification in Anesthesiology� (MOCA�)

WISER's MOCA � simulation course is a fun, fast-paced and challenging experience. During the simulation sessions, participants will manage patients with hypoxia and hemodynamic instability in the setting of general surgical, neurosurgical, obstetric care and pediatric surgery. These Saturday classes run from 7:30 am to 3:00 pm.

A press release from the American Academy of Pain Medicine (AAPM) describes new research from Ajay D. Wasan, MD, MSc showing that scientists can predict the effectiveness of nonsteroidal anti-inflammatory drugs (NSAIDs) in treating pain by assessing the nervous system's own capacity to regulate pain. Dr. Wasan's study showed that patients whose tests had indicated superior conditioned pain modulation had less pain and fewer neuropathic symptoms.

Jacques E. Chelly, MD, PhD, MBA was appointed a member of the Committee for Tenured Faculty Promotions and Appointments (TFPA) for a three-year term of service beginning January 1, 2014 through December 31, 2016.

Rita M. Patel, MD was presented with a 2013 University of Pittsburgh Innovator Award from the Office of Technology Development at the Celebration of Innovation held at the University Club on November 14, 2013.

On October 19, 2013, the ABA held the first-ever exam for board certification in the subspecialty of pediatric anesthesiology. Twenty-seven department faculty members became pioneers by receiving the first ABA certification in pediatric anesthesiology.

Current UPMC transitional year resident Richard Hubbard, MD authored a children's book, The Day I had my Surgery. He wrote the book as a Virginia Commonwealth University (VCU) medical student. VCU Medical Center is now distributing the book in the pre-operation clinic appointments office, as part of a packet given to families of pediatric patients. One-thousand copies have been printed and Hubbard estimates the first run will last about six months.

Shu Yang Lu

Mr. Shu Yang Lu (University of Pittsburgh Medical Student -III) was selected to receive a Young Investigator Award at the 2014 Joint International Congress of the International Liver Transplantation Society (ILTS), European Liver and Intestine Transplant Association (ELITA), and Liver Intensive Care Group of Europe (LICAGE) on June 4-7 in London, United Kingdom. He will receive a check for $1,000 US, an award certificate, and complimentary congress registration. His abstract, entitled "Applicability of Rapid Thrombelastography and Functional Fibrinogen Assay in Adult Liver Transplantation" (Lu SY, Tanaka KA, Abuelkasem E, Planinsic RM, Sakai T), was also chosen as a prestigious oral presentation at the meeting. Mr. Lu's mentor is Tetsuro Sakai, MD, PhD.

"Cellular Registration without Behavioral Recall of Olfactory Sensory Input under General Anesthesia" (Andrew R. Samuelsson, PhD; Nicole R. Brandon, MS; Pei Tang, PhD; Yan Xu, PhD. Anesthesiology 2014; 120(4):890-905.Anesthesiology 2014; 120(4):890-905) reveals new findings that suggest the brain receives and registers sensory information at the cellular level while anesthetized without behavioral reporting of the same information after recovering from anesthesia. In the study, rats were exposed to a specific odor while under general anesthesia. Examination of the brain tissue after they had recovered from anesthesia revealed evidence of cellular imprinting, even though the rats behaved as if they had never encountered the odor before.

"What's New on the Horizon and Case Studies: Potential Problems, Staying out of Trouble"

Rita M. Patel, MD, Chair of the Academic Home and Scholarship Committee for the Association of American Medical Colleges, will present "Promoting Scholarship in Your Institution" to the Group on Resident Affairs on May 6, 2014.

Dr. Steven L. Orebaugh

Steven L. Orebaugh, MD will serve on the faculty for the upcoming American Society of Regional Anesthesia and Pain Medicine (ASRA) annual meeting in Chicago, April 3-6, 2014. He will also teach at two workshops and present two point-counterpoint lectures with roundtable discussions.

Dr. Tetsuro Sakai

Tetsuro Sakai, MD, PhD will present "Facilitation of Resident Scholarly Activity: University of Pittsburgh Medical Center Experience" and the Anesthesiology Grand Round "Challenges in Liver Transplantation" Lecture for Trainees at the University of Maryland School of Medicine, Baltimore, ML, April 2-3, 2014.

Dr. Brian A. Williams

Brian A. Williams, MD, MBAwill present the PBLD "OR efficiency: what role does regional anesthesia play?" and the pro/con Lecture: "PRO: A Block Area is Required for an Efficient Block Practice" at the Annual ASRA Meeting in Chicago, April 5-7, 2014.

Please help us continue the tradition of excellence by supporting the department with your tax deductible gift. Your support will enable us to expand our efforts in teaching, research and clinical care. To learn more about ways to support the department, include the department in your estate plans, or about planned or differed gifts, or gifts of securities, please contact: